Skip to main content

Full text of "On the neurosis following enteric fever known as the typhoid spine"

See other formats




ON THE NEUROSIS FOLLOWING ENTERIC FEVER, 
KNOWN AS " THE TYPHOID SPINE." 



By WILLIAM OSLER, M. D. 



From the Johns Hopkins Hospital Reports, Vol. IV, No. 1, Baltimore, Md. 



I^^MHHI 




Y._ON THE NEUROSIS FOLLOWING ENTERIC FEVER, 
KNOWN AS "THE TYPHOID SPINE." 

By WILLIAM OSLER, M.D. 

In 1889 Dr. Gibney, of New York, described at the American 
Orthopaedic Association a sequel of enteric fever which he called 
"the typhoid spine," and which he regarded as a perispondylitis, 
" meaning an acute inflammation of the periosteum and the fibrous 
structures which hold the spinal column together." He stated that 
his reason for the use of the term " was the production of acute pain 
on the slightest movement, whether lateral or forward, and the 
absence of any marked febrile disturbance or neuralgia." He 
described four cases ; in the first, a lad of 15, towards the end of con- 
valescence, complained of severe pain in the back, particularly in the 
lumbar region, and especially after any movement. There was no 
disease of the bone, no pain in the distribution of the sciatic or 
anterior crural nerve. He was seen in the autumn of 1882, with 
Dr. Beverly Robinson. A spinal brace afforded relief, and in the 
course of two or three weeks he was practically well, but the brace 
was worn for more than a year. 

The second case, a young man aged 24, had an attack of typhoid 
fever which ran a normal course. After convalescence was well 
established he complained of pain in the back, but he was able to be 
up and about, and played tennis. After a fall at tennis the pain 
became very severe, and he suffered so excruciatingly that he could 
only rest in a recumbent posture. Deep pressure over the iliac 
region on the left side, and lateral or antero-posterior motion of the 
spine, caused excessive pain. He had some fever. The symptoms 
persisted from the latter part of November until the beginning of 
January, but it was not until March that he was able to get about. 

The third case, a lad of 18, had typhoid fever in November, was 
convalescent by December 27th, and went to New York. On January 
10th he fell while skating and struck his left hip. A week after this 
he had pain in the region of the lumbar spine. The stiffness became 
more marked and the pains increased in severity. On the 10th of 



74 William Osier. [74 

February ho went to bed and was seen by a surgeon in Albany, who 
regarded the case as one of psoas abscess. There was no fever, no 
evidence of disease of the spine, but the patient could not move with- 
out exquisite pain. He did not recover until May. 

The fourth case seems to me to belong to an entirely different 
category, as it was an instance in which, during typhoid fever, the 
boy had kept both limbs flexed on the abdomen, and during conva- 
lescence was unable to straighten them, an event met with in many 
protracted illnesses in which the patient lies curled up in bed with 
the legs flexed. 

In 1890, in a discussion at the Association of American Physicians 
following the reading of a paper on some points in the natural history 
of enteric or typhoid fever, by Dr. James E Reeves,* Dr. Loomis, Sr., 
referred to Dr. Gibney's observations, and to one of the cases he had 
asked Dr. Gibney to see. Dr. Loomis knew of no reference in litera- 
ture to a similar condition. Dr. Jacobi, at the same meeting, besides 
protesting against the introduction of a new name, such as " typhoid 
spine," suggested that, in the absence of temperature, it might be 
one of two things, either a neurosis or a spondylitis, remarking that 
mild forms of spondylitis are not so uncommon as they are believed 
to be. 

In the American Text-book of Medicine (page 90) Dr. Pepper 
remarks in his article on typhoid fever that he has observed in a 
series of cases " obstinate peri-osteitis of the sternum or of the crests 
of the ilia, or in two instances, judging from the location of the pain 
and from the effect of movement of the trunk, of the front of the 
spinal column." Eskridge also described a case last year. 

I have not been able to find any other references in text-books or 
monographs on typhoid fever, either in English, French or German. 
My attention had not been called to the condition until recently, 
unless perhaps a case which I saw several years ago with Dr. Gra- 
sett, of Toronto, was an illustration ; a young officer, invalided from 
India after a prolonged fever, had for many months, on the slightest 
movement, attacks of the most severe pain in the back, which 
incapacitated him completely, though when seen by me he looked 
strong and robust and had a good appetite. He subsequently got 
quite well. 

* Transactions of the Association of American Physicians, vol. v., 1890. 



75] The Typhoid Spine. 75 

The two following cases are, I think, illustrative of the condition 
which Dr. Gibney has described : 

Case I. — O. T., aged 25 (Hos. No. 8201), admitted complaining 
of pains in the back, hips and stomach. The family history is good. 
His father and mother are living and well. One brother died of 
typhoid fever. 

Patient was strong and well until July, 1892, when he had a very 
severe attack of typhoid fever with relapse. He was in bed for 
nearly three months; very slow convalescence. He remained well 
for three weeks, when the present illness began with pains in the 
back and hips, usually of a shooting character, and paroxysms of 
pain in the abdomen, of which he would sometimes have several in 
the day. He had to take again to his bed and was there for seven 
weeks, having much pain in the lower part of the back and down 
the front of the legs. He never apparently, from his account, had 
any paralysis. About June of this year he was well enough 
to go out and do light work about the farm. In the latter part 
of June he had another attack of severe pain in the back and 
abdomen. He had not to go to bed. There was much aching pain 
and shooting in the right leg from the hip down to the knee. In 
the latter part of July and in August he had severe attacks of 
diarrhoea. Since August he has been up and about, but not work- 
ing, and has been able to go out shooting. At present he has slight 
pains at times in the back and in the legs, and yesterday there was an 
aching pain from the left knee to the ankle. The appetite is good. 
He never vomits, though he often has eructations. Bowels are 
costive. He sometimes has dyspnoea on exertion. 

Present Condition. — Healthy looking, well-nourished man, with 
fairly well-developed musculature. He gives one the impression of 
a neurasthenic patient. Lips and mucous membranes of good color ; 
tongue clean and moist; pupils equal; pulse 70° to 80°; no increase 
in tension. Practically the examination of the thoracic and abdom- 
inal organs was negative. The abdomen was soft and nowhere 
tender. The chief complaint is of weakness in the back, and it 
hurts him to turn in bed. He describes the pain which he had last 
year as beginning in the small of the back, passing around the hip 
bones and then up the back. Judging from the scarring, the chief 
trouble was thought to be in the lower part of the spine. There is 
still a little tenderness on pressure just above the left sacro-iliac 



76 William Osier. [76 

synchondrosis. There is no tenderness over the sacrum itself, or 
along the iliac crests. Patient gets out of bed readily and stands 
well ; walks with a natural gait; does not sway with the eyes shut. 
After prolonged standing or walking he complains of great increase 
of pains in the back. The knee-jerks are present, a little exagger- 
ated ; there is no ankle clonus. The most careful examination of 
the spine fails to reveal any signs of organic disease. The urine is 
normal. 

The patient remained in hospital for a little more than a week j 
took large doses of nux vomica, and was encouraged to believe that 
he had no serious organic disease. Subsequent examinations gave 
no additional information, but the patient evidently was highly 
neurasthenic. 

Case II. — A. A., aged 21, architect's assistant, seen with Dr. King, 
May 10th, 1893. Patient has always been a healthy man and has 
never had any very serious illness. He is not of a robust constitu- 
tion, and though bright, not of a very strong mental fibre. There 
are no special nervous troubles in the family. 

In November and December last, patient had typhoid fever, an 
attack of moderate severity. On New Year's day he sat up for the 
first time, and convalescence was gradually established. There were 
no sequelae, no complications, and early in February he went to his 
work. He gained in weight and looked very well. He remained 
at work about three weeks, complaining only at times of pain in the 
back and of being very tired after sitting for a long time. One day 
he was very much jarred in the back during a sudden jerking of a 
cable car in which he was riding. Early in March, after complain- 
ing very much of his back and of the pain on moving, and of tired 
feelings, he took to his bed, where he has remained ever since. 
Dr. King tells me that the chief symptom has been pain on move- 
ment. His general health has been excellent. The appetite has 
been good, he has gained in weight, and he has slept well. He has 
been nervous and at times almost hysterical. When quiet and at 
rest and not attempting any movement he does not complain of pain, 
but on turning or on attempting to get out of bed, or even the 
thought of the attempt to move the legs, is enough to cause him to 
cry out. The pains have been in the lower part of the back, extend- 
ing sometimes up the spine and down the back and sides, more 



77] The Typhoid Spine. 77 

rarely the front of the leg as far as the knee. He has had no fiver, 
no chills, but has sweated a good deal. He h:ts had no swelling of 
the joints. 

Present Condition. — Patient is a well-grown young man, well nour- 
ished, musculature of moderate development. The palms of the 
hands are moist and sweating; he was somewhat excited, and at 
our entrance flushed over the cheeks and neck and upper part of the 
chest. Face does not indicate any special strength of character, 
rather the reverse. Pupils of medium size, equal, active; tongue 
clean. Patient in the dorsal decubitus, his usual attitude. On 
pulling down the bedclothes he implored us not to touch him, as he 
was sure it would hurt him very much. The abdomen was full, 
natural looking. On palpation he complained of a good deal of 
pain in the left iliac region, but on withdrawing his attention and 
pressing forcibly with the left hand in the region of the heart and 
asking whether he had pain here, the right hand at the same time 
could be pressed deeply into the iliac fossa without causing any dis- 
turbance. The deepest pressure in the lumbar and iliac regions 
failed to reveal any glandular enlargements or thickening. The 
inguinal glands not enlarged; no special sensitiveness along the ante- 
rior crural nerves. On asking him to lift the leg he said it 
was impossible, as it hurt him so much, but in a few moments, 
placing the hand beneath it, he lifted it apparently without pain. 
When lifted in a semi-flexed position he said it was impossible for 
him to straighten it, but in a few moments it could be readily 
extended and he straightened it easily on the bed. There was 
no special wasting of the legs. He could move all the muscles 
freely and was able to get up and stand on his legs if he took time. 
The sensation was perfect ; the knee-jerks present, perhaps a little 
exaggerated ; no ankle clonus. The feet and ankles were perspiring 
freely. No swelling of the articulations, and no pain on pressure of 
the muscles or in the popliteal spaces. On asking him to turn over 
on his left side he demurred very much, but gradually, and apparently 
with a great deal of difficulty, he got himself over. The legs could 
then be moved easily and freely ; no pain about the hip joint, and 
the legs could be flexed and extended readily. The spine was 
straight; the lower dorsal vertebras a little prominent. Xo tender- 
ness at any point along the spinal column. On both sides in the 
lower lumbar and sacral regions he was sensitive at a distance of an 



78 William Oder. [78 

inch and a half or two inches from the middle line, and particularly 
towards the right sacro-iliac synchondrosis, and along the posterior 
third of the crest of the ileum. He stated that this was really the 
point of greatest pain. Any attempt at twisting the spinal column 
was very sensitive and we could not induce him to sit up. In the 
attempts to make this movement he seemed to suffer a great deal 
of pain and began to cry. 

There were no sensory changes, no hemianesthesia, no hemi- 
anopsia. The patient said that his chief trouble was more the dread 
of moving, lest it should cause pain, than any pain itself. Four 
days ago he sat up for a couple of hours, got out of bed himself and 
sat on the chair, but felt very tired, and the back was painful. Prac- 
tically the examination in this case revealed neither Potts' disease 
nor neuritis. 

He was ordered massage and electricity, and the Paquelin cautery 
to the back, given strychnia internally, and urged to sit up a certain 
definite time each day. 

June 10th. A few days after I saw him he was able to sit up and 
did very well. Went out on the 30th of May and has been doing 
remarkably well ever since. Called to-day, looks in very good con- 
dition. No pain in the back ; feels a little stiff; knee jerks are 
normal; condition good. 

Cases II and III in Dr. Gibney\s paper are very much like the 
one here mentioned, particularly in the fact that the symptoms devel- 
oped after convalescence, and in both instances there was a slight 
trauma ; in one a fall while playing tennis, and in another a slight 
fall on the left hip while skating. In the case reported here the 
patient also lays a great deal of stress on the jar which he received 
by the sudden jerking of the cable car. In both of these cases the 
prominent symptom was pain on movement, and there was an absence 
of all signs of organic disease. 

An explanation of the symptoms in these cases is by no means easy. 
As already mentioned, Dr. Gibney regarded the lesion as a peri- 
spondylitis, an acute inflammation of the periosteum and fibrous 
structures holding the spinal column together ; and with this view, 
judging from the quotation given, Dr. Pepper seems to agree. 

Joint and periosteal troubles are by no means rare sequences of 
typhoid fever, but the symptoms do not usually develop (as in three 



79] The Typhoid Spirit. 79 

or four of the cases here described) at so long a time after convales- 
cence has been well established. The periostitis, seen of'tene.-t aboul 
the sternum and the ribs, proceeds as a rule, but not necessarily, 
to suppuration. I have in several instances seen a periosteal swelling 
disappear without suppuration. We do not have, so far afl I know, 
protracted periosteal thickening, lasting for weeks or months, without 
suppuration : and it is difficult to conceive of the attacks of pain, Buch 
as are described in the second and third cases of Dr. Gibney's, and 
in the second case which I here report, lasting for months, du< 
simple perispondylitis which in none of the cases passed on to sup- 
puration. In both of my cases the general impression given by the 
patients was that they were neurasthenic ; and while of course it would 
be very illogical to assume that all of the instances are due to the 
same cause, yet I cannot help feeling that many of them are examples 
simply of the painful neurosis formerly known as " spinal irritation/' 
and analogous to the painful condition met with in the " hysterical 
spine " and the "railway spine," in both of which the patient may 
have pains on the slightest movement of the back or of the legs. In 
the second case reported, the whole behavior during the examination 
was that of a hysterical patient; thus, he could not think of lifting 
a leg — even the idea was enough to give him agonizing pain, and 
yet in a few minutes he lifted it himself and got out of bed. So also 
the slightest pressure in the lumbar or iliac regions would cause him 
to scream out, but while his attention was directed elsewhere, pres- 
sure could be made with the greatest facility. The rapid recovery 
in a few days, with disappearance of all the symptoms, is quite 
inconsistent with a chronic perispondylitis. 

I have recently seen a case presenting somewhat different features, 
but which I think may also be reasonably classed as a post-typhoid 
neurosis. 

Case III. — A. B., aged about 30, New York City, consulted me 
Nov. 2nd, 1893, stating that he had had trouble with his spinal cord. 
Family history was good ; parents living ; one sister, however, is 
insane. 

He was nervous as a boy; used to tremble very much when 
excited, and had "nervous fits." He had gonorrhoea three or four 
times; never had lues; acknowledges excesses in ventre. Takes 
alcohol, but is not a hard drinker. 

September 23rd, 1891, he had an attack of typhoid fever of unusual 



80 William Oder. [80 

severity, with prolonged delirium, extensive bed-sores, and very great 
prostration. Convalescence was not established until January 10th, 
1892. During and after convalescence he was very nervous, and 
had uneasy pains in the legs, his feet were tender, and he tired very 
easily. He had no pain in the back, no soreness, but the tenderness 
in the feet and nervous feelings persisted for six or eight months after 
convalescence, and he does not think that they have ever entirely 
disappeared. He attended, however, to his business, gained in 
weight, and felt pretty well, though never entirely free from uneasv 
sensations in the feet and legs. In the spring of this year these 
symptoms increased, particularly after some sprees. He had neur- 
algic pains in the legs, and he felt weak and unstrung, and evidently 
got into a very nervous condition. He had a dread of walking, and 
could scarcely force himself to go as far as the corner of the street. 
He slept badly and got into a state of extreme neurasthenia. There 
were twitchings of the muscles, and the feet and hands felt numb, and 
he complained that when his shoes and stockings were off there was 
a smooth feeling as if something was between the feet and the floor. 
At this time a doctor in New r York suggested there was oncoming 
spinal trouble, and stated that in testing the sensation over the 
spine with hot and cold water he could not distinguish between 
them. He ordered him electricity and massage and general tonics ; 
for the past seven or eight weeks he has not been at work and has 
improved a good deal. 

Present Condition. — Tall, able-bodied man ; looks a little pale ; 
gait is normal; not spastic; station good; no Romberg symptom; 
no atrophy of the muscles ; legs scarcely in proportion, however, to 
the rest of the muscular development. The spine is straight, nowhere 
painful on pressure, no special prominence of any vertebra. Sensa- 
tion is everywhere good, no retardation, distinguishes easily between 
heat and cold. He thinks that about the feet and ankles the sensation 
is a little blurred and unnatural. He feels, however, a sharp point, 
and distinguishes readily different objects, and the thermic and pain- 
ful sensations are unaffected. He has no abnormal sensations about 
the back and abdomen, and has not any sense of constriction or 
girdle pain. There is no vaso-motor disturbance. He sweats, how- 
ever, easily and the hands are clammy, and he has had at times, he 
states, marked blueness and congestion of the feet, and they are often 
cold in the morning. 



81] The Typhoid Spin,: 81 

The reflexes are increased; knee-jerks active, particularly on the 
left side, and a slight ankle clonus can be obtained. The skin reflexes 
are normal. There is no disturbance of the special senses. The 

pupils are a little large, equal, react to light. The optic disl 
normal; there is no restriction of the visual fields. 

The examination of the thoracic and abdominal organs is negative. 

Here, after a protracted and severe attack of typhoid fever with 
delirium, severe nervous symptoms and tardy convalescence, th<- 
patient had disturbed sensations in the feet and legs. The symp- 
toms diminished somewhat within five or six months, never entirely 
disappeared, and recurred with intensity during a period character- 
ized by pronounced neurotic manifestations. Unlike the cases before 
described, there were no pains in the back or abdomen, only a sen- 
sation of weakness. The symptoms suggest: (1) central (spinal) 
lesion ; (2) neuritis ; or (3) a neurosis. From his statements it was 
evident that the doctor in attendance feared a central affection, but 
it would seem that the patient's condition now, two years from the 
date of the fever, would speak very strongly against any such view ; 
nor does the case conform in its clinical history to a neuritis. The 
man insists that the same feelings which he has now in the feet were 
present during the convalescence from the attack and some months 
subsequently. There did not appear to have been any very special 
muscular weakness such as sometimes develops after a protracted 
attack of typhoid fever without any evidence of peripheral neuritis. 
In the paper by Dr. George Ross on Paralysis after Typhoid Fever* 
he refers to these cases in the following words : "It is not unusual 
after typhoid fever of considerable severity to find a definitely 
enfeebled condition of the lower extremities persisting for some time, 
and sometimes a person never entirely recovers his capacity for 
walking long distances. Such paretic cases have never been specially 
studied, but it is probable they would, if any should fall under the 
head of defective innervation from prolonged exhaustion of the 
nervous centres." In the case under discussion, the history and the 
general appearance of the patient suggest rather a neurosis following 
typhoid fever. The paresthesias such as he described are not 
uncommon symptoms of neurasthenia, in which also exaggerated 
reflexes are not at all infrequent. 

* Transactions of the Association of American Physicians, Vol. Ill, 18S8. 



82 William Osier. [82 

It is not unlikely that under the designation of " typhoid spine" 
Dr. Gibneyhas described several distinct affections, and I would not 
be understood as holding that there may not be a perispondylitis. 
Nor indeed are all the painful backs in typhoid fever neurotic; thus, 
a patient recently under my care (Hos. No. 8049) was admitted in an 
attack of moderate severity about the end of the third week, the tem- 
perature falling to normal by the 26th day; then after a period of 
apyrexia of seven or eight days he had a well-marked relapse of about 
two weeks' duration. During convalescence he began to complain 
of severe pain in the back of the neck, and at the attachment of the 
muscles of the occipital bone. There was no actual tenderness in the 
vertebras, and movements to and fro and laterally were not associated 
with any very great pain. An application of the Paquelin cautery 
relieved it for a few days, and then it recurred. The examination 
from the pharynx was negative. The condition persisted for at least 
two weeks, and while at first confined to the neck, subsequently he 
had soreness and stiffness of the back; he walked stiffly and held 
himself very erect. He says that it is better when moving about 
than when lying down. No special tenderness in the spine, and no 
sharp pain; no increase in the reflexes; no indication of neuritis. 
He gradually improved, and when discharged he was very much 
better, having gained 11 J pounds in weight. 






■*■ "«>. cam* ua.